A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Bradycardia.

Muffled heart sounds

Flattened neck veins.

Sudden lethargy.

Answer and Explanation

The Correct Answer is B

B. Muffled heart sounds, often described as distant or indistinct, are classic findings in cardiac tamponade. The accumulation of fluid in the pericardial sac dampens the transmission of sound from the heart to the chest wall, resulting in muffled heart sounds on auscultation. This finding is known as Beck's triad, which also includes hypotension and jugular venous distention.

A. Bradycardia is not a typical finding in cardiac tamponade. In fact, tachycardia is more commonly observed due to the compensatory response to decreased cardiac output and decreased stroke volume. The sympathetic nervous system is activated, leading to an increase in heart rate as a compensatory mechanism to maintain cardiac output.

C. Flattened neck veins are not consistent with cardiac tamponade. In cardiac tamponade, jugular venous distention (JVD) is typically observed due to increased venous pressure resulting from impaired right ventricular filling. The presence of JVD is an important clinical finding in cardiac tamponade and can help differentiate it from other causes of shock.

D. Sudden lethargy can occur in various medical emergencies, including cardiac tamponade, but it is not a specific or diagnostic finding for this condition. In cardiac tamponade, symptoms may include dyspnea, chest pain, hypotension, and signs of decreased cardiac output such as cool extremities and altered mental status. However, sudden lethargy alone may not be specific enough to confirm cardiac tamponade.

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Correct Answer is C

Explanation

C Atrial fibrillation (AF) is characterized by rapid, irregular electrical activity in the atria, leading to an irregularly irregular ventricular response. AF often results in palpitations, fatigue, and dizziness due to the irregular heart rhythm and inefficient cardiac output. A significant pulse deficit may also be present due to the irregularity of the ventricular response compared to the atrial activity. Given the sudden onset of irregular palpitations, fatigue, dizziness, and a significant pulse deficit, atrial fibrillation is a likely dysrhythmia in this scenario.

A First-degree AV block is characterized by a prolonged PR interval on the electrocardiogram (ECG), indicating delayed conduction between the atria and ventricles. While it can indicate conduction system abnormalities, it typically does not result in rapid or irregular palpitations, fatigue, or dizziness.

Therefore, it is less likely to be the cause of the client's symptoms.

B Sinus tachycardia is characterized by a rapid heart rate originating from the sinus node, typically with a regular rhythm. While sinus tachycardia can cause palpitations and fatigue, it is less likely to result in an irregular heart rate with a significant pulse deficit. Therefore, it is less likely to be the cause of the client's symptoms.

D Sinus bradycardia is characterized by a slow heart rate originating from the sinus node. While sinus bradycardia can cause fatigue and dizziness, it typically does not result in a rapid or irregular heart rate. Therefore, it is less likely to be the cause of the client's symptoms.

A. Elective cardioversion B. Defibrillation C. Radiofrequency catheter ablation D. CPR

Correct Answer is A

Explanation

A. Elective cardioversion involves the synchronized delivery of a therapeutic electrical shock to the heart to restore normal sinus rhythm in a patient with a tachyarrhythmia, such as atrial fibrillation or atrial flutter. However, ventricular tachycardia (VT) is a life-threatening arrhythmia characterized by a rapid heart rate originating from the ventricles, and it requires immediate intervention due to the risk of deteriorating into ventricular fibrillation (VF) and cardiac arrest. Therefore, elective cardioversion is not appropriate for treating VT.

B. Defibrillation involves the unsynchronized delivery of a high-energy electrical shock to the heart to terminate life-threatening arrhythmias, such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). In the case of a conscious patient with pulse-sustaining ventricular tachycardia, immediate defibrillation may not be necessary. However, if the patient deteriorates into pulseless VT or VF, prompt defibrillation is required to restore normal cardiac rhythm and circulation.

C. Radiofrequency catheter ablation is a procedure performed in a cardiac catheterization lab to treat certain cardiac arrhythmias by delivering radiofrequency energy to the specific area of the heart responsible for the abnormal rhythm. While radiofrequency catheter ablation may be considered for certain types of sustained ventricular tachycardia that are refractory to medical therapy or deemed to be originating from a specific site in the heart, it is not the immediate intervention for hemodynamically unstable ventricular tachycardia.

D. CPR is an emergency procedure performed on individuals experiencing cardiac arrest or a life- threatening medical emergency. In the case of ventricular tachycardia (VT) with a pulse, the patient is still perfusing, and CPR is not indicated. However, if the patient deteriorates into pulseless VT or ventricular fibrillation (VF), CPR may be initiated along with immediate defibrillation.

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A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

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Naxlex Comprehensive Predictor Exams

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

Correct Answer is C

Explanation

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

Correct Answer is A

Explanation

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